The international position on laparoscopic liver surgery: The Louisville Statement, 2008

Comparison of clinical and economic outcomes between minimally invasive liver resection and open liver resection: a propensity-score matched analysis

BACKGROUND

Minimally invasive liver resection (MILR) has gained momentum in recent years. This study of contemporary data compares economic and clinical outcomes between MILR and open liver resection (OLR).

METHODS

We extracted data for patients undergoing liver resection between October 2015-September 2018 from the Premier Healthcare Database. We conducted a propensity score matched analysis to compare complications, in-hospital mortality, inpatient readmissions, discharge to institutional post-acute care, operating room time (ORT), length of stay (LOS), and total hospital cost between MILR and OLR patients.

RESULTS

From the eligible OLR (n = 3349) and MILR (n = 1367) patients, we propensity score matched 1261 from each cohort at a 1:1 ratio. After matching, MILR was associated with lower rates of complications (bleeding: 8.2% vs. 17.4%; respiratory failure: 5.5% vs. 10.9%; intestinal obstruction: 3.6% vs. 6.0%, and pleural effusion: 1.9% vs. 4.9%), in-hospital mortality (0.5% vs. 3.0%), 90-day inpatient readmissions (10.4% vs. 14.3%), discharge to institutional post-acute care (6.9% vs. 12.3%), shorter ORT (257 vs. 308 min) and LOS (4.3 vs. 7.2 days), and lower hospital costs ($19463 vs. $29119) (all P < 0.001).

CONCLUSION

MILR was associated with lower risk of complications and reduced hospital resource utilizations as compared with OLR.

Robot-assisted versus laparoscopic minor hepatectomy: A systematic review and meta-analysis

BACKGROUND

Robot-assisted and laparoscopic surgery are the most minimally invasive surgical approaches for the removal of liver lesions. Minor hepatectomy is a common surgical procedure. In this study, we evaluated the advantages and disadvantages of robot-assisted vs laparoscopic minor hepatectomy (LMH).

METHODS

A systematic literature search was performed in PubMed, Embase, and the Cochrane Library to identify comparative studies on robot-assisted vs. laparoscopicminor hepatectomy up to February, 2020. The odds ratios (OR) and mean differences with 95% confidence intervals were calculated using the fixed-effects model or random-effects model.

RESULTS

A total of 12 studies involving 751 patients were included in the meta-analysis. Among them, 297 patients were in the robot-assisted minor hepatectomy (RMH) group and 454 patients were in the LMH group. There were no significant differences in intraoperative blood loss (P = .43), transfusion rates (P = .14), length of hospital stay (P > .64), conversion rate (P = .62), R0 resection rate (P = .56), complications (P = .92), or mortaliy (P = .37) between the 2 groups. However, the RMH group was associated with a longer operative time (P = .0003), and higher cost (P < .00001) compared to the LMH group. No significant differences in overall survival or disease free survival between the 2 groups were observed. In the subgroup analysis of left lateral sectionectomies, RMH was still associated with a longer operative time, but no other differences in clinical outcomes were observed.

CONCLUSIONS

Although RMH is associated with longer operation times and higher costs, it exhibits the same safety and effectiveness as LMH. Prospective randomized controlled clinical trials should now be considered to obtain better evidence for clinical consensus.

Hand-assisted Laparoscopic Repeat Hepatectomy for Secondary Liver Neoplasm

BACKGROUND

Hand-assisted laparoscopic surgery is a widely accepted alternative to an open approach. The use of this technique in repeat liver resection is limited due to technical difficulties caused by postsurgical adhesions. We aimed to assess the feasibility and safety of hand-assisted laparoscopic repeat hepatectomy (HALRH).

MATERIALS AND METHODS

This was a retrospective study of the medical files of patients who had undergone HALRH between 2010 and 2017 in 2 university-affiliated medical centers.

RESULTS

Sixteen patients with repeat hepatectomy were included with a median age of 67.5 years. The first liver resection was a traditional laparotomy for 9 patients and hand-assisted laparoscopic surgery for 7 patients. The conversion rate to open surgery was 6%. The median operative time, blood loss during surgery, and postoperative hospital stay were 166 minutes, 400 mL, and 7 days, respectively. R0 resections were achieved in 88% of patients. The median number of tumors and tumor size were 1 and of 25 mm, respectively. There were no mortalities or major complications postoperatively. For patients with colorectal liver metastases, the median follow-up and overall survival were 21 and 43 months, respectively.

CONCLUSION

The findings suggest HALRH to be safe and feasible. Future ERAS guidelines should evaluate this approach for liver surgery.

Laparoscopic or open treatment for hepatic alveolar echinococcosis: A single-institution experience

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of laparoscopy in the treatment of hepatic alveolar echinococcosis (AE).

METHODS

Between January 2018 and December 2019, 213 hepatic AE patients were admitted to the authors' institution. Among them, 165 patients (77.46%, 165/213) underwent surgery. Of 13 patients who underwent laparoscopic treatment, two required conversion to open surgery. The remaining 11 patients (group 1) were analyzed. During the same period, 154 patients underwent open surgery, but only 14 records were compatible with the criteria for the laparoscopic approach and were reviewed retrospectively (group 2).

RESULTS

Conversion to open surgery occurred in two cases. Both groups were basically consistent in terms of detailed demographic data, characteristics of the lesions, and surgical strategy (P > 0.05). The laparoscopic group not only achieved the same R0 resection as the open group, but the results were also significantly superior to those of the open group in terms of postoperative complications, postoperative catheterization time, and postoperative hospital stay (P = 0.042, P = 0.046, and P = 0.045, respectively). No recurrences were observed in either group during this period.

CONCLUSIONS

Laparoscopic surgery provides a safe and efficacious approach for hepatic AE in selected patients. Large, prospective, randomized trials are needed to confirm its superiority.

Comparison of surgical outcomes for laparoscopic liver resection of large hepatocellular carcinomas: A retrospective observation from single-center experience

BACKGROUND/PURPOSE

Although laparoscopic liver resection (LLR) is a common surgical procedure for hepatocellular carcinoma (HCC), its suitability for large HCCs (≥5 cm) remains controversial. This study compared surgical outcomes of open hepatectomy with LLR for large HCCs.

METHODS

A total of 313 patients with HCC who underwent hepatectomy between January 2010 and June 2017 were analyzed retrospectively. Demographic data, short-term outcomes, and long-term survivals were analyzed.

RESULTS

Among patients with large HCCs (n = 122), the open group (n = 85) had larger tumor sizes (10.91 ± 4.72 vs. 7.45 ± 2.95 cm; p < 0.001) and more advanced stages (stages 3/4: 71.8% vs. 45.9%; p = 0.029) than the LLR group (n = 37), while LLR group achieved less blood loss (623.24 ± 841.75 mL vs. 1091.76 ± 1004.72 mL, p = 0.014) and shorter LOS (9.00 ± 5.13 d vs. 12.82 ± 8.51 d, p = 0.013). There were no significant differences in complication and mortality rates between groups. The 5-year overall and recurrence-free survival rates between the two groups were not significantly different (p = 0.408 and 0.644 respectively). The surgical outcomes showed equal benefit of the two operation types.

CONCLUSION

With sufficient surgeon experience and appropriate patient selection, LLR is a feasible treatment choice for large HCCs.

Cost-Benefit Analysis of Robotic vs. Laparoscopic Hepatectomy: A Propensity-Matched Retrospective Cohort Study of American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Robotic and laparoscopic hepatectomies having increased utilization as minimally invasive techniques are explored for hepatobiliary malignancies. Although the data on outcomes from these 2 approaches are emerging, the cost-benefit analysis of these approaches remains sparse. This study compares the costs associated with robotic vs. laparoscopic liver resections, taking into account 30-day complications.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, a propensity-matched cohort of patients with laparoscopic or robotic liver resections between 2014 and 2017 was identified. Costs were assigned to perioperative variables, including operating room (OR) time, length of stay, blood transfusions, and 30-day complications. Cost estimates were obtained from the Centers for Medicare and Medicaid Services billing data (2017), American Hospital Association data (2017), relevant literature, and local institutional cost data.

RESULTS

In our matched cohort of 454 patients (227 per group), total costs associated with laparoscopic liver resections were estimated at $5.5 M ($24 K per patient) vs. $6.8 M ($29.8 K per patient) for robotic liver resections (21.3% difference, P < .001). The higher cost associated with robotic hepatectomies was related to blood transfusions ($22.0 K vs. $12.1 K, P = .02), length of stay ($2.05 M vs. $1.76 M, P = .046), and OR time ($4.01 M vs. $3.24 M, P < .0001).

DISCUSSION

Robotic hepatectomies were associated with higher costs compared to laparoscopic hepatectomies. The 2 major contributors to the cost disparity were increased OR time and increased length of stay. Future studies are warranted to analyze high-volume Minimally Invasive Surgery surgeons' impact in specialty centers on potentially mitigating this current cost disparity.

Robotic and laparoscopic liver resection-comparative experiences at a high-volume German academic center

Purpose

Minimally invasive liver surgery (MILS) is a feasible and safe procedure for benign and malignant tumors. There has been an ongoing debate on whether conventional laparoscopic liver resection (LLR) or robotic liver resection (RLR) is superior and if one approach should be favored over the other. We started using LLR in 2010, and introduced RLR in 2013. In the present paper, we report on our experiences with these two techniques as early adopters in Germany.

Methods

The data of patients who underwent MILS between 2010 and 2020 were collected prospectively in the Magdeburg Registry for Minimally Invasive Liver Surgery (MD-MILS). A retrospective analysis was performed regarding patient demographics, tumor characteristics, and perioperative parameters.

Results

We identified 155 patients fulfilling the inclusion criteria. Of these, 111 (71.6%) underwent LLR and 44 (29.4%) received RLR. After excluding cystic lesions, 113 cases were used for the analysis of perioperative parameters. Resected specimens were significantly bigger in the RLR vs. the LLR group (405 g vs. 169 g, p = 0.002); in addition, the tumor diameter was significantly larger in the RLR vs. the LLR group (5.6 cm vs. 3.7 cm, p = 0.001). Hence, the amount of major liver resections (three or more segments) was significantly higher in the RLR vs. the LLR group (39.0% vs. 16.7%, p = 0.005). The mean operative time was significantly longer in the RLR vs. the LLR group (331 min vs. 181 min, p = 0.0001). The postoperative hospital stay was significantly longer in the RLR vs. the LLR group (13.4 vs. LLR 8.7 days, p = 0.03). The R0 resection rate for solid tumors was higher in the RLR vs. the LLR group but without statistical significance (93.8% vs. 87.9%, p = 0.48). The postoperative morbidity ≥ Clavien-Dindo grade 3 was 5.6% in the LLR vs. 17.1% in the RLR group (p = 0.1). No patient died in the RLR but two patients (2.8%) died in the LLR group, 30 and 90 days after surgery (p = 0.53).

Conclusion

Minimally invasive liver surgery is safe and feasible. Robotic and laparoscopic liver surgery shows similar and adequate perioperative oncological results for selected patients. RLR might be advantageous for more advanced and technically challenging procedures.

Outcomes of surgery for giant hepatic hemangioma

BACKGROUND

The surgical indications for liver hemangioma remain unclear.

METHODS

Data from 152 patients with hepatic hemangioma who underwent hepatectomy between 2004 and 2019 were retrospectively reviewed. We analyzed characteristics including tumor size, surgical parameters, and variables associated with Kasabach-Merritt syndrome and compared the outcomes of laparoscopic and open hepatectomy. Here, we describe surgical techniques for giant hepatic hemangioma and report on two meaningful cases.

RESULTS

Most (63.8%) patients with hepatic hemangioma were asymptomatic. Most (86.4%) tumors from patients with Kasabach-Merritt syndrome were larger than 15 cm. Enucleation (30.9%), sectionectomy (28.9%), hemihepatectomy (25.7%), and the removal of more than half of the liver (14.5%) were performed through open (87.5%) and laparoscopic (12.5%) approaches. Laparoscopic hepatectomy is associated with an operative time, estimated blood loss, and major morbidity and mortality rate similar to those of open hepatectomy, but a shorter length of stay. 3D image reconstruction is an alternative for diagnosis and surgical planning for partial hepatectomy.

CONCLUSION

The main indication for surgery is giant (> 10 cm) liver hemangioma, with or without symptoms. Laparoscopic hepatectomy was an effective option for hepatic hemangioma treatment. For extremely giant hemangiomas, 3D image reconstruction was indispensable. Hepatectomy should be performed by experienced hepatic surgeons.

Laparoscopic liver resection for huge (≥10 cm) hepatocellular carcinoma: A coarsened exact-matched single-surgeon study

INTRODUCTION

Laparoscopic liver resection (LLR) is increasingly being utilised worldwide for the management of both benign and malignant liver tumours. However, there is limited data to date regarding the safety and feasibility of this approach for huge (≥10 cm) hepatocellular carcinomas (HCCs). We present here our early experience performing LLR for huge HCCs.

METHODS

We conducted a retrospective review of 280 consecutive patients who underwent LLR by a single surgeon from 2012 to August 2020.15 patients had a preoperative radiological diagnosis of huge (≥10 cm) HCC. Coarsened exact-matched (CEM) weighting was used to compare them to 101 patients who underwent LLR for non-huge HCC.

RESULTS

After CEM-weighting, both groups were well-balanced for baseline variables. There was no difference in the rates of open conversion. The huge HCC patients had a higher mean Iwate difficulty score than the non-huge HCC patients (9.13 vs 6.53, p = 0.007). As such, the median operating time for the huge HCC group was longer (360 min vs 240min, p = 0.049). However, there were no significant differences in estimated blood loss, proportion of patients requiring blood transfusion, utilization of Pringle maneuver or median Pringle duration. Post-operatively, there were no significant differences in median LOS, overall and major morbidity rates, and 90-day mortality rates between both groups. Median resection margins were also similar for both cohorts.

CONCLUSION

LLR may be performed successfully for selected patients with huge HCC, with encouraging perioperative outcomes and no compromise in oncologic efficacy.

Laparoscopic Liver Resection Should Be a Standard Procedure for Hepatocellular Carcinoma with Low or Intermediate Difficulty

BACKGROUND

To investigate the feasibility of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC), we compared the outcome between LLR and conventional open liver resection (OLR) in patient groups with different IWATE criteria difficulty scores (DS).

METHODS

We retrospectively reviewed 607 primary HCC patients (LLR: 81, OLR: 526) who underwent liver resection in Linkou Chang Gung Memorial hospital from 2012 to 2019. By using 1:1 propensity score-matched (PSM) analysis, their baseline characteristics and the DS stratified by the IWATE criteria were matched between the LLR and OLR. Their perioperative and oncologic outcomes were compared.

RESULTS

After 1:1 PSM, 146 patients (73 in LLR, 73 in OLR) were analyzed. Among them, 13, 41, 13 and 6 patients were classified as low, intermediate, advanced and expert DS group, respectively. Compared to OLR, the LLR had shorter hospital stay (9.4 vs. 11.5 days, p = 0.071), less occurrence of surgical complications (16.4% vs. 30.1%, p = 0.049), lower rate of hepatic inflow control (42.5% vs. 65.8%, p = 0.005), and longer time of inflow control (70 vs. 51 min, p = 0.022). The disease-free survival (DFS) and overall survivals were comparable between the two groups. While stratified by the DS groups, the LLR tended to have lower complication rate and shorter hospital stay than OLR. The DFS of LLR in the intermediate DS group was superior to that of the OLR (p = 0.020). In the advanced and expert DS groups, there were no significant differences regarding outcomes between the two groups.

CONCLUSION

We have demonstrated that with sufficient experience and technique, LLR for HCC is feasible and the perioperative outcome is favorable. Based on the current study, we suggest LLR should be a standard procedure for HCC with low or intermediate difficulty. It can provide satisfactory postoperative recovery and comparable oncological outcomes. Further larger scale prospective studies are warranted to validate our findings.

Robotic liver surgery: literature review and future perspectives

INTRODUCTION

Minimally invasive liver resections (MILR) have been gaining popularity over the last decades. MILR provides superior peri-operative outcome. Despite these advantages, the penetrance of MILR in the clinical setting has been limited, and it was slowed down, among other factors, also by the laparoscopic technological limitations.

EVIDENCE ACQUISITION

A literature review has been carried out (Pubmed, Embase and Scopus platforms) focusing on the role of robotic surgery in MILR.

EVIDENCE SYNTHESIS

The literature review results are presented and our additional remarks on the topic are discussed.

CONCLUSIONS

Robotic MILR has been helping to expand the penetrance of MIS in liver surgery by making possible increasingly more challenging procedures. Minor resections still represent most of the robotic liver surgery data currently available. Robotic liver surgery is safe and effective, and it shows perioperative outcomes comparable with laparoscopic and open surgery. The oncological efficacy, within the limitations of the current level of evidence (mostly retrospective studies and literature heterogeneity), seems to show promising result. High quality prospective randomized studies, the use of prospective registry data, and multi-institutional efforts are needed.

Intrahepatic cholangiocarcinoma as the new field of implementation of laparoscopic liver resection programs. A comparative propensity score-based analysis of open and laparoscopic liver resections

BACKGROUND

The aim of the present study is to analyze the outcomes of laparoscopic and open liver resections for (Intrahepatic CholangioCarcinoma) ICC in the modern era of laparoscopic liver surgery.

METHODS

Patients undergoing laparoscopic and open liver resections for ICC in two European referral centers were included. Finally, 104 patients from the open group and 104 patients from the laparoscopic group were compared after propensity scores matching according to seven covariates representative of patients and disease characteristics. Indications to surgery and short- and long-term outcomes were compared.

RESULTS

Operative time, number of retrieved nodes, rate, and depth of negative resection margins were comparable between the two groups. Blood loss was lower in the MILS (150 ± 100 mL, mean ± SD) compared with the Open group (350 ± 250 mL, p = 0.030). Postoperative complications occurred in 14.4% of patients in the MILS and in the 24% of patients in the Open group (p = 0.02). There were no significant differences in long-term outcomes between groups.

CONCLUSIONS

Our results confirm feasibility, safety, and oncological efficiency of the laparoscopic approach in the management of ICC. However, this surgery is often complex and should be only considered in centers with large experience in laparoscopic liver surgery.

Evolutions in the Management of Hepatocellular Carcinoma over Last 4 Decades: An Analysis from the 100 Most Influential Articles in the Field

INTRODUCTION

Over the past 4 decades, the management of hepatocellular carcinoma (HCC) has changed dramatically. The publications that have had the most significant impact on HCC management have not been quantitatively analyzed. In this article, we analyzed the 100 most influential articles over the past 4 decades using bibliometric citation analysis to characterize the evolution in HCC treatment.

METHODS

The top-cited publications were identified and analyzed from the Clarivate Analytics Web of Science Core Collection database.

RESULTS

The 100 most cited articles were identified with an average of 738 citations (range: 349-6,799). There was an increase in the number of influential articles in the late 1990s, which was paralleled by an increase in reports focused on locoregional treatment of HCC. Most top 100 articles came from the USA (n = 35), followed by Italy (n = 28), mainland China (n = 26), and Japan (n = 24). The surgical management was the most studied topic (n = 33). The Annals of Surgery published the highest number of papers (n = 26) with 13,978 citations. While other 3 topics (surgical management, locoregional treatment, and outcome prediction) declined among publications beginning in the 2000s, there was an emergence of highly cited papers on targeted drugs and immune checkpoint inhibitors with a concomitant increase in the number of publications on systemic therapy.

CONCLUSIONS

Based on bibliometric analysis of the literature over the last 40 years, a comprehensive analysis of the most historically significant HCC management articles highlighted the key contributions made to the evolution and advancement of this specialist field. The data should provide clinicians and researchers insight into future directions relative to the advancement of HCC management.

Hand-assisted Laparoscopic Surgery for Colorectal Liver Metastasis: Analysis of Short-term and Long-term Results

BACKGROUND

There is scant data regarding the outcomes of hand-assisted laparoscopic surgery (HALS) for colorectal liver metastasis (CRLM). The aim of this study is to report our experience and analyze the short-term and long-term results.

MATERIALS AND METHODS

Retrospective study of patients undergoing HALS for CRLM in 2 university affiliated medical centers.

RESULTS

Two hundred and thirty-eight liver procedures were performed on 145 patients including 205 parenchymal sparing resections and 33 anatomic resections. The median number of metastases was 1 (range: 1 to 8), 38 patients (26.2%) had 3 or more metastases, and 41 patients (28.3 had a bi-lobar disease. The tumor size was 20 (2 to 90) mm, and 52 patients (36.6%) had a tumor larger than 30 mm. Nighty-nine patients (67.8%) received neoadjuvant chemotherapy. In 8 patients (5.5%) the laparoscopic liver resection was combined with ablation, and 16 patients (11%) underwent a synchronous resection of colorectal cancer. The median operative time, blood loss during surgery, and postoperative hospital stay were 163 minutes, 300 mL, and 4 days, respectively. The median modified Iwate complexity score was 4 (0 to 10) and the conversion rate to open surgery was 5.5%. The overall and major complication rates were 23.8% and 3.6%, respectively. The mortality rate was 0.7%. R0 resections were achieved in 91% of patients. Median overall survival for all the cohort (intend to treat) was 59 months, and the 8- and 10-year overall survival rates were 47.3% and 24.9%, respectively.

CONCLUSIONS

This study shows that HALS is a safe and efficacious treatment for selected patients with CRLM.

A snapshot of the 2020 conception of anatomic liver resections and their applicability on minimally invasive liver surgery. A preparatory survey for the Expert Consensus Meeting on Precision Anatomy for Minimally Invasive HBP Surgery

BACKGROUND

The main aim of this survey was to analyze how liver surgeons perform liver resections and to define their conception of anatomic procedures within the incorporation of minimally invasive liver surgery (MILS).

METHODS

The survey was distributed among liver surgeons. It mainly focused on personal experience on open and MILS, methods and landmarks, and experience on anatomic resections and Glissonean approach.

RESULTS

A total of 445 valid answers from 54 countries was obtained. Surgeons performing MILS mainly have below 10 years of experience (81.8% of responders) and one third has never done complex MILS. New techniques, including indocyanine green demarcation are marginally used (<25%). More than 60% of surgeons do not make a full exposure of hepatic veins during MILS, mainly due to the risk of injury or not considering it to be of utility. Although 88% of responders agreed with the concept of anatomic resection as the "resection along the border/watersheds of each order division identified by the portal vein flow", only 55% of surgeons have ever performed MILS Glissonean approaches.

CONCLUSIONS

Liver anatomy is not a static concept. Anatomic resections need training and precision. Standardization of complex anatomic resections by a minimally invasive approach should be encouraged.

Technical feasibility and short-term outcomes of laparoscopic isolated caudate lobe resection: an IgoMILS (Italian Group of Minimally Invasive Liver Surgery) registry-based study

Background

Although isolated caudate lobe (CL) liver resection is not a contraindication for minimally invasive liver surgery (MILS), feasibility and safety of the procedure are still poorly investigated. To address this gap, we evaluate data on the Italian prospective maintained database on laparoscopic liver surgery (IgoMILS) and compare outcomes between MILS and open group.

Methods

Perioperative data of patients with malignancies, as colorectal liver metastases (CRLM), hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), non-colorectal liver metastases (NCRLM) and benign liver disease, were retrospectively analyzed. A propensity score matching (PSM) analysis was performed to balance the potential selection bias for MILS and open group.

Results

A total of 224 patients were included in the study, 47 and 177 patients underwent MILS and open isolated CL resection, respectively. The overall complication rate was comparable between the two groups; however, severe complication rate (Dindo–Clavien grade ≥ 3) was lower in the MILS group (0% versus 6.8%, P = ns). In-hospital mortality was 0% in both groups and mean hospital stay was significantly shorter in the MILS group (P = 0.01). After selection of 42 MILS and 43 open CL resections by PSM analysis, intraoperative and postoperative outcomes remained similar except for the hospital stay which was not significantly shorter in MILS group.

Conclusions

This multi-institutional cohort study shows that MILS CL resection is feasible and safe. The surgical procedure can be technically demanding compared to open resection, whereas good perioperative outcomes can be achieved in highly selected patients.

[Minimally invasive liver surgery]

Minimally invasive liver surgery is safe and can be performed with results practically equal to those in open surgery. There are different techniques of parenchyma dissection and hemostasis available for the safe performance of minor and major resections, both laparoscopically and robotics based. Due to its technical options robotics-based surgery is a further development of laparoscopy. Expertise in minimally invasive and in liver surgery are essential prerequisites.

Laparoscopic versus open hepatectomy for intrahepatic cholangiocarcinoma: An individual patient data survival meta-analysis

BACKGROUND

We compared the outcomes of laparoscopic hepatectomy (LH) vs. open hepatectomy (OH) for intrahepatic cholangiocarcinoma (iCCA).

METHODS

A systematic review of the MEDLINE, EMBASE, Scopus, and Cochrane Library databases was performed using PRISMA guidelines (end-of-search date: 08-June-2020). Individual patient data on overall survival (OS) and recurrence-free survival (RFS) were extracted. Random-effects meta-analyses, and one- and two-stage survival analyses were conducted.

RESULTS

Eight retrospective cohort studies comparing LH (n = 544) vs. OH (n = 2256) were identified. LH demonstrated lower overall complication (Risk ratio [RR] = 0.64, 95% confidence interval [CI]: 0.46-0.90; p = 0.01), surgical lymphadenectomy (RR = 0.74, 95% CI: 0.58-0.93; p = 0.01) and margin-positive resection (RR = 0.78, 95% CI: 0.62-0.99; p = 0.04) rates, and higher recurrence-free rate (RR = 1.24, 95% CI: 1.01-1.51; p = 0.04) vs. OH. In Cox regression, no difference was observed regarding OS (Hazard Ratio [HR] = 1.11, 95% CI: 0.65-1.91; p = 0.70) and RFS (HR = 1.19, 95% CI: 0.74-1.90; p = 0.47).

CONCLUSION

The use of LH should be considered when feasible in well-selected iCCA patients by hepatobiliary surgeons with experience in minimally-invasive surgery.

Economic analysis of open versus laparoscopic versus robotic hepatectomy: a systematic review and meta-analysis

BACKGROUND

Following the publication of reports from landmark international consensuses (Louisville 2008 and Morioka 2014), minimally invasive hepatectomy became widely accepted as a legitimate alternative to open surgery. We aimed to compare the operative, hospitalization, and total economic costs of open (OLR) vs. laparoscopic (LLR) vs. robotic liver resection (RLR).

METHODS

We performed a systematic literature review (end-of-search date: July 3, 2020) according to the PRISMA statement. Random-effects meta-analyses were conducted. Quality assessment was performed with the Cochrane Risk of Bias tool for randomized controlled trials, and the Newcastle-Ottawa Scale for non-randomized studies.

RESULTS

Thirty-eight studies reporting on 3847 patients (1783 OLR; 1674 LLR; 390 RLR) were included. The operative costs of LLR were significantly higher than those of OLR, while subgroup analysis also showed higher operative costs in the LLR group for major hepatectomy, but no statistically significant difference for minor hepatectomy. Hospitalization costs were significantly lower in the LLR group, with subgroup analyses indicating lower costs for LLR in both major and minor hepatectomy series. No statistically significant difference was observed regarding total costs between LLR and OLR both overall and on subgroup analyses in either major or minor hepatectomy series. Meta-analyses showed higher operative, hospitalization, and total costs for RLR vs. LLR, but no statistically significant difference regarding total costs for RLR vs. OLR.

CONCLUSION

LLR's higher operative costs are offset by lower hospitalization costs compared to OLR leading to no statistically significant difference in total costs, while RLR appears to be a more expensive alternative approach.

Rationality and necessity of vascular stapler application during liver resection (Review)

Liver resection (LR) is the primary treatment method for patients with hepatocellular carcinoma (HCC). Improving surgical safety and reducing surgical morbidity and mortality is important for patients receiving LR. Various devices have been developed to facilitate vascular transection to reduce intraoperative blood loss, which is considered to be a predictor of poor surgical outcomes in patients undergoing LR. Vascular staplers have been widely applied for the division of major vascular and biliary structures in the process of LR; however, when and how to use these tools remains controversial. This review aims to report the rationality and necessity of using vascular staplers in vessel transection during liver surgery. Due to the risk of intraoperative and postoperative hemorrhage and biliary fistula, the process of transection of the portal pedicle and hepatic vein is a crucial step during LR. Stapling represents a vascular dissection technique that is widely used in laparoscopic LR and has then been popularized in open LR. Advocates argue that stapler transection methods provide several advantages, including diminished blood loss, fewer transfusion requirements and shorter operative times. However, other studies have failed to demonstrate those benefits when using these tools compared with the simple clamp-crushing technique. Using the stapler vascular transection method resulted in smaller surgical margins and similar surgical outcomes compared with those of the clamp-crushing vascular transection method. However, the intraoperative use of vascular staplers may significantly increase the financial burden of liver resection for patients with HCC, while not improving short- and long-term outcomes. Therefore, it has been suggested that vascular staplers should not be routinely used in LR. The current review discussed the above points and recommended that the stapling transection of the portal pedicle and hepatic vein should be applied during laparoscopic LR in a rational manner. However, the suturing ligation method should be routinely used in open LR.

Minimally invasive versus open right anterior sectionectomy and central hepatectomy for central liver malignancies: a propensity-score-matched analysis

BACKGROUND

The utility of minimally-invasive liver resection (MILR) for deep centrally located tumours (CLT) remains controversial. We aimed to review our institution's experience and outcomes with minimally invasive central hepatectomy (CH) and right anterior sectionectomy (RAS) for CLT in a propensity score-matched (PSM) analysis.

METHODS

Retrospective review of a prospectively maintained surgical database revealed 23 patients who underwent MILR (6 CH, 17 RAS) and 53 patients who underwent open liver resection (OLR; 24 CH, 29 RAS) for CLT. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Peri-operative outcomes were then compared.

RESULTS

There was one laparoscopic-assisted, one robot-assisted and two laparoscopic-converted-open procedures in the MILR cohort. Across the unmatched cohort, there was only one mortality (MILR) and five patients with major morbidity (all OLR). MILR was associated with a longer operating time (P < 0.001), but shorter post-operative hospital stay (P = 0.002) and decreased morbidity (P = 0.018) in the unmatched cohort. Examination of peri-operative outcomes after PSM revealed that MILR was similarly associated with a longer operating time (P = 0.001) and shortened post-operative hospital stay (P = 0.043). OLR was associated with a significantly reduced application of Pringle manoeuvre (P = 0.004). There were no significant differences between MILR and OLR with regards to blood loss, blood transfusions, morbidity and margin status in the PSM analysis.

CONCLUSION

MILR for CLT is safe and feasible when performed by experienced surgeons. It is associated with shorter hospital stays but at the expense of longer operation times and more frequent application of Pringle manoeuver.

Minimally invasive versus open radical resection surgery for hilar cholangiocarcinoma: Comparable outcomes associated with advantages of minimal invasiveness

Background

Minimally invasive surgery (MIS) provides a new approach for patients with hilar cholangiocarcinoma (HCCA). However, whether it can achieve similar outcomes to traditional open surgery (OS) remains controversial.

Methods

To assess the safety and feasibility of MIS for HCCA, a systematic review and meta-analysis was performed to compare the outcomes of MIS with OS. Seventeen outcomes were assessed.

Results

Nine studies involving 382 patients were included. MIS was comparable in blood transfusion rate, R0 resection rate, lymph nodes received, overall morbidity, severe morbidity (Clavien–Dindo classification > = 3), bile leakage rate, wound infection rate, intra-abdominal infection rate, days until oral feeding, 1-year overall survival, 2-year overall survival and postoperative mortality with OS. Although operation time was longer (mean difference (MD) = 93.51, 95% confidence interval (CI) = 64.10 to 122.91, P < 0.00001) and hospital cost (MD = 0.68, 95% CI = 0.03 to 1.33, P = 0.04) was higher in MIS, MIS was associated with advantages of minimal invasiveness, that was less blood loss (MD = -81.85, 95% CI = -92.09 to -71.62, P < 0.00001), less postoperative pain (MD = -1.21, 95% CI = -1.63 to -0.79, P < 0.00001), and shorter hospital stay (MD = -4.22, 95% CI = -5.65 to -2.80, P < 0.00001).

Conclusions

The safety and feasibility of MIS for HCCA is acceptable in selected patients. MIS is a remarkable alternative to OS for providing comparable outcomes associated with a benefit of minimal invasiveness and its application should be considered more.

Body mass index and surgical outcomes in laparoscopic liver resections: a systematic review

BACKGROUND

Laparoscopic liver resection is gaining momentum; however, there is limited evidence on its efficacy and safety in obese patients. The aim of this study was to examine the relationship between BMI and outcomes after laparoscopic liver resection (LLR) using a systematic review of the existing literature.

METHODS

A systematic search of Medline (Ovid 1946-present), PubMed (NCBI), Embase (Ovid 1966-present) and Cochrane Library was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for parameters of LLR and BMI. Operative, post-operative and oncological outcomes were recorded.

RESULTS

Of 1460 abstracts, seven retrospective studies were analysed, published between 2015 and 2017 (study periods 1998-2017). Total patient cohort were classified as 481 obese and 1180 non-obese with a median age range of 42.5-69.4 years. Variations existed in definitions of obesity (Asia BMI >25 kg/m² , Western BMI >30 kg/m² ). Rates of conversion were examined in four studies (0-31%) with one reporting BMI >28 kg/m² as an independent risk factor. Estimated blood loss and transfusion rates were similar. Operative time was increased in obese patients in one study (P = 0.02). Mortality rates ranged from 0% to 4.3% with no difference between BMI classes. No difference in major morbidity was demonstrated. Bile leak rates were increased in obese groups in one study (0-3.44%, P < 0.05). Wound infections were reported in five studies, with higher rates in obese patients (0-5.8% versus 0-1.9%). Tumour size was comparable in both groups. Completeness of resection was analysed in four studies with one study reporting increased R0 rates in obese patients (P = 0.012).

CONCLUSION

This systematic review highlights that current evidence shows LLR in obese patients is safe, however, further studies are required.

Robotic ICG guided anatomical liver resection in a multi-centre cohort: an evolution from "positive staining" into "negative staining" method

BACKGROUND

Laparoscopic major anatomical liver resection is challenging. The robotic liver resection (RLR) approach, with Firefly indocyanine green (ICG) imaging, was proposed to overcome the limitations of laparoscopy. The aim of this multi-centre international study was to evaluate the use of Firefly ICG imaging in anatomical RLR.

METHODS

A retrospective study of consecutive patients undergoing RLR anatomical resection with intra-operative ICG administration from January 2015 to July 2018 were enrolled. Patients who underwent simultaneous or en-bloc resections of other organs were excluded.

RESULTS

A total of 52 patients were recruited of which 32 patients were healthy donors, 17 with malignancy and 3 for benign conditions. 12 patients had cirrhosis. 28 patients underwent a right hepatectomy (53.8%) with left hepatectomy performed with 18 patients. 40 patients underwent negative staining and 12 patients via direct portal vein injection for positive staining. ICG demarcation line was visualized in 43 patients and was clearer than the ischaemic demarcation line in 29 patients. All resections for malignancy had clear margins. There were no 30-day/inpatient mortalities.

CONCLUSION

Robotic ICG guided hepatectomy technique for anatomical liver resection is safe, feasible and has the benefit for improved visualization in healthy donors and cirrhotic patients.

Laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma: A propensity case-matched analysis of the long-term survival

Backgrounds/Aims

Despite the widespread popularity of laparoscopic surgery, laparoscopic liver resection (LLR) remains in evolution. This study aimed to compare the long-term outcomes for patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC) ≤7 cm.

Methods

Patients diagnosed with HCC treated by hepatectomy from October 2000 to May 2019 were included. Excluding tumors larger than 7 cm, 1:2 propensity score matching was performed between laparoscopic and open hepatectomies. The perioperative outcomes, 5-year overall survival (OS) and disease-free survival (DFS) of the two groups were compared.

Results

Forty-five patients who underwent LLR were matched to 90 open hepatectomy (OH) during the same period. LLR group had shorter median hospital stay (5 days vs. 9 days, p=0.00) but required longer operative time (326.0 minutes vs. 272.5 minutes, p=0.018) than the OH group. The 5-year overall survival was better in the LLR group (84.9% vs. 61.1%; p=0.036), though there was no significant difference in the 5-year disease free survival (20.0% vs. 22.2%, p=0.613). The rate of R0 resection was comparable between the 2 groups with a slightly better margin distance in the LLR (5 mm vs. 3 mm, p=0.043).

Conclusions

Laparoscopic liver resection is safe and feasible for cirrhotic patients with HCC size up to 7 cm. It has better short-term outcomes and comparable perioperative blood loss and complication rates. The resection margin is not jeopardized and the 5-year overall and disease-free survivals are comparable with the open group.

Patterns, timing, and predictors of recurrence after laparoscopic liver resection for hepatocellular carcinoma: results from a high-volume HPB center

Background

Although long-term outcomes may be comparable between laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC), there has been little discussion regarding the patterns of recurrence after LLR.

Methods

Patients with HCC who underwent hepatectomy between April 2015 and November 2018 were included in this study. The recurrence patterns were analyzed in detail. The recurrence outcomes following laparoscopic versus OLR for HCC were compared after 1:2 propensity score matching. Potential risk factors for recurrence were also assessed with Cox proportional risk models.

Results

Among 425 patients after LLR, 144 (33.8%) experienced recurrence at the last follow-up, with a median recurrence-free survival (RFS) of 10.0 months (range 1–58 months). The most frequent recurrence site was the liver (n = 99, 68.8%), followed by the surgical margin (n = 15, 10.4%) and distant metastases (n = 12, 8.3%). Liver recurrence with distant metastasis (n = 10, 6.9%) tended to occur early (median 8.0 months), while peritoneal recurrence (n = 8, 5.6%) occurred later (median 14.0 months). A total of 120 (83.3%) patients had recurrence within 2 years after LLR. No trocar site recurrence was observed in this study. The recurrence patterns, timing, and treatment did not show significant differences between the LLR and OLR. The independent risk factors for recurrence included ALBI grade, postoperative α-fetoprotein > 8 ng/ml, tumor size > 5 cm, surgical margin ≤ 1 cm, and multiple tumors. Patients with recurrence had 1- and 5-year overall survival rates of 81.1% and 60.7%, respectively, compared with rates of 95.8% and 92.9% for patients without recurrence (P < 0.000).

Conclusion

This study suggested that intrahepatic recurrence was still the most common recurrence pattern for HCC after LLR and that LLR did not increase the risk of trocar hole recurrence or implantation. Most cases of recurrence occurred within 2 years after LLR, suggesting that surveillance should be targeted to early recurrence.

Supplementary Information

The online version of this article (10.1007/s00464-021-08390-5) contains supplementary material, which is available to authorized users.

Laparoscopic Liver Resection Using a Silicone Band Retraction Method (With Video)

Supplemental Digital Content is available in the text.

The success of laparoscopic liver resection (LLR) depends on stable and full exposure of the parenchymal transection plane. We evaluated the efficacy of LLR using a silicone band retraction method for lesions in the anterolateral and posterosuperior segments.

Laparoscopic Versus Open Liver Resection for Tumors in the Posterosuperior Segments: A Systematic Review and Meta-analysis

OBJECTIVE

The objective of this study was to compare the outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. We conducted a search of electronic information sources to identify all studies comparing outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments. We used the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I) tool to assess the risk of bias of the included studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

RESULTS

We identified 11 observational studies, enrolling a total of 1023 patients. The included population in both groups were comparable in terms of baseline characteristics. Laparoscopic approach was associated with lower risks of total complications [odds ratio (OR): 0.45; 95% confidence interval (CI): 0.33, 0.61; P<0.00001], major complications (Dindo-Clavien III or more) (OR: 0.52; 95% CI: 0.36, 0.73; P=0.0002), and intraoperative blood loss [mean difference (MD): -114.71; 95% CI: -165.64, -63.79; P<0.0001]. Laparoscopic approach was associated with longer operative time (MD: 50.28; 95% CI: 22.29, 78.27; P=0.0004) and shorter length of hospital stay (MD: -2.01; 95% CI: -2.09, -1.92; P<0.00001) compared with open approach. There was no difference between the 2 groups in terms of need for blood transfusion (OR: 1.23; 95% CI: 0.75, 2.02; P=0.41), R0 resection (OR: 1.09; 95% CI: 0.66, 1.81; P=0.72), postoperative mortality (risk difference: -0.00; 95% CI: -0.02, 0.02; P=0.68), and need for readmission (OR: 0.70; 95% CI: 0.19, 2.60; P=0.60). In terms of oncological outcomes, there was no difference between the groups in terms disease recurrence (OR: 1.58; 95% CI: 0.95, 2.63; P=0.08), overall survival (OS) at maximum follow-up (OR: 1.09; 95% CI: 0.66, 1.81; P=0.73), 1-year OS (OR: 1.53; 95% CI: 0.48, 4.92; P=0.47), 3-year OS (OR: 1.26; 95% CI: 0.67, 2.37; P=0.48), 5-year OS (OR: 0.91; 95% CI: 0.41, 1.99; P=0.80), disease-free survival (DFS) at maximum follow-up (OR: 0.91; 95% CI: 0.65, 1.27; P=0.56), 1-year DFS (OR: 1.04; 95% CI: 0.60, 1.81; P=0.88), 3-year DFS (OR: 1.13; 95% CI: 0.75, 1.69; P=0.57), and 5-year DFS (OR: 0.73; 95% CI: 0.44, 1.24; P=0.25).

CONCLUSIONS

Compared with the open approach in liver resection for tumors in the posterosuperior segments, the laparoscopic approach seems to be associated with a lower risk of postoperative morbidity, less intraoperative blood loss, and shorter length of hospital stay with comparable survival and oncological outcomes. The best available evidence is derived from observational studies with moderate quality; therefore, high-quality randomized controlled trials with adequate statistical power are required to provide a more robust basis for definite conclusions.

Ultrasound-guided transmuscular quadratus lumborum block reduced postoperative opioids consumptions in patients after laparoscopic hepatectomy: a three-arm randomized controlled trial

Background

To investigate whether transmuscular quadratus lumborum block (TQLB) combined with oxycodone-based patient-controlled intravenous analgesia (PCIA) compared with sufentanil-based patient-controlled intravenous analgesia could reduce postoperative pain and opioid consumption in patients undergoing laparoscopic hepatectomy.

Methods

Eighty patients undergoing laparoscopic hepatectomy surgery were randomly divided into Group S (Sufentanil for PCIA group), Group O (Oxycodone for PCIA group) and Group QO (transmuscular quadratus lumborum block + oxycodone for PCIA group). Primary outcome was Numerical Rating Scale (NRS) pain score when coughing at 6th hour after the operation. We summarized opioid consumption and recorded complications, opioid drug adverse reaction and analgesia satisfaction.

Results

NRS pain scores were significantly lower in Group QO while patients coughing at 6th hour after the operation compared with Group S and Group O (median (interquartile range [IQR]):Group S vs. Group O vs. Group QO 4.0 [3.0, 5.0] vs. 4.0[3.0,5.0]vs.3.0 [2.0, 3.0], p < 0.05). Within 24 h after surgery, the bolus times of PCIA (patient controlled intravenous analgesia) in the QO group was reduced which was compared with the Group S and Group O (median (interquartile range [IQR]):Group S vs. Group O vs. Group QO 13.0 [10.3, 19.5] vs. 11.5 [7.8, 18.3]vs.6.5[3.5,12.0], p < 0.05). The proportion of patients in the three groups who required additional analgesia was ranked as Group QO < Group O < Group S(p < 0.05). The analgesic satisfaction of patients in Group QO was higher than the Group S (p = 0.001) and Group O (p = 0.012).

Conclusions

TQLB combined with oxycodone-based PCIA provided satisfactory postoperative analgesia and reduced oxycodone consumption in patients following laparoscopic hepatectomy.

Trial registration

ChiCTR1900028467 (22/12/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01255-3.

Feasibility of laparoscopic liver lobectomy in dogs

OBJECTIVE

To determine the feasibility of laparoscopic liver lobectomy (LLL) in dogs by using canine cadavers and to describe the clinical application in dogs with liver disease.

STUDY DESIGN

Ex vivo experiment and descriptive case series.

SAMPLE POPULATION

Twelve canine cadavers and six client-owned dogs.

METHODS

Cadavers underwent LLL with an endoscopic stapler. The percentage of liver lobe resected was determined by volume. The distance from the staple line to hilus was measured. Medical records of dogs undergoing LLL were reviewed.

RESULTS

In cadavers ≤15 kg, left lateral lobectomy completeness was 87.3% (84.6%-96.6%), and remaining median (interquartile range) hilar length was 1 cm (0.25-1.75). Left medial lobectomy completeness was 72.5% (66.7%-80%), and remaining hilar length was 1.6 cm (0.47-1.75). Central division resection completeness was 68.3% (60%-92.9%), and remaining hilar length was 2.7 cm (0.8-5). Laparoscopic liver lobectomy was not feasible for right division lobes and in cadavers >15 kg. Five dogs with peripheral quadrate or left lateral lobe masses underwent stapled, partial laparoscopic lobectomy (30%-90%). One dog underwent stapled, left lateral lobectomy (90%) after open procedure conversion. Histopathological diagnoses included hepatocellular carcinoma (3), nodular hyperplasia (1), biliary cyst adenoma (1), and fibrosis (1).

CONCLUSION

Laparoscopic liver lobectomy of the left and central divisions is feasible in cadavers ≤15 kg with an endoscopic stapler. Partial LLL of the left and central divisions is feasible in select dogs with liver disease.

CLINICAL SIGNIFICANCE

Laparoscopic liver lobectomy may be a viable alternative to laparotomy in small-to-medium size dogs with peripheral liver masses of the left and central divisions.

Expert Consensus Guidelines on Minimally Invasive Donor Hepatectomy for Living Donor Liver Transplantation From Innovation to Implementation: A Joint Initiative From the International Laparoscopic Liver Society (ILLS) and the Asian-Pacific Hepato-Pancreato-Biliary Association (A-PHPBA)

OBJECTIVE

The Expert Consensus Guidelines initiative on MIDH for LDLT was organized with the goal of safe implementation and development of these complex techniques with donor safety as the main priority.

BACKGROUND

Following the development of minimally invasive liver surgery, techniques of MIDH were developed with the aim of reducing the short- and long-term consequences of the procedure on liver donors. These techniques, although increasingly performed, lack clinical guidelines.

METHODS

A group of 12 international MIDH experts, 1 research coordinator, and 8 junior faculty was assembled. Comprehensive literature search was made and studies classified using the SIGN method. Based on literature review and experts opinions, tentative recommendations were made by experts subgroups and submitted to the whole experts group using on-line Delphi Rounds with the goal of obtaining >90% Consensus. Pre-conference meeting formulated final recommendations that were presented during the plenary conference held in Seoul on September 7, 2019 in front of a Validation Committee composed of LDLT experts not practicing MIDH and an international audience.

RESULTS

Eighteen Clinical Questions were addressed resulting in 44 recommendations. All recommendations reached at least a 90% consensus among experts and were afterward endorsed by the validation committee.

CONCLUSIONS

The Expert Consensus on MIDH has produced a set of clinical guidelines based on available evidence and clinical expertise. These guidelines are presented for a safe implementation and development of MIDH in LDLT Centers with the goal of optimizing donor safety, donor care, and recipient outcomes.

Operative Time, Age, and Serum Albumin Predict Surgical Morbidity After Laparoscopic Liver Surgery

Background. Laparoscopic liver resection (LLR) has emerged as a considerable alternative to conventional liver surgery. However, the increasing complexity of liver resection raises the incidence of postoperative complications. The aim of this study was to identify risk factors for postoperative morbidity in a monocentric cohort of patients undergoing LLR. Methods. All consecutive patients who underwent LLR between 2015 and 2019 at our institution were analyzed for associations between complications with demographics and clinical and operative characteristics by multivariable logistic regression analyses. Results. Our cohort comprised 156 patients who underwent LLR with a mean age of 60.0 ± 14.4 years. General complications and major perioperative morbidity were observed in 19.9% and 9.6% of the patients, respectively. Multivariable analysis identified age>65 years (HR = 2.56; P = .028) and operation time>180 minutes (HR = 4.44; P = .001) as significant predictors of general complications (Clavien ≥1), while albumin<4.3 g/dl (HR = 3.66; P = .033) and also operative time (HR = 23.72; P = .003) were identified as predictors of major postoperative morbidity (Clavien ≥3). Conclusion. Surgical morbidity is based on patient- (age and preoperative albumin) and procedure-related (operative time) characteristics. Careful patient selection is key to improve postoperative outcomes after LLR.

Glissonean approach for hepatic inflow control in minimally invasive anatomic liver resection: A systematic review

BACKGROUND

The Glissonean approach has been widely validated for both open and minimally invasive anatomic liver resection (MIALR). However, the possible advantages compared to the conventional hilar approach are still under debate. The aim of this systematic review was to evaluate the application of the Glissonean approach in MIALR.

METHODS

A systematic review of the literature was conducted on PubMed and Ichushi databases. Articles written in English or Japanese were included. From 2,390 English manuscripts evaluated by title and abstract, 43 were included. Additionally, 23 out of 463 Japanese manuscripts were selected. Duplicates were removed, including the most recent manuscript.

RESULTS

The Glissonean approach is reported for both major and minor MIALR. The 1st, 2nd and 3rd order divisions of both right and left portal pedicles can be reached following defined anatomical landmarks. Compared to the conventional hilar approach, the Glissonean approach is associated with shorter operative time, lower blood loss, and better peri-operative outcomes.

CONCLUSIONS

Glissonean approach is safe and feasible for MIALR with several reported advantages compared to the conventional hilar approach. Clear knowledge of Laennec's capsule anatomy is necessary and serves as a guide for the dissection. However, the best surgical approach to be performed depends on surgeon experience and patients' characteristics. Standardization of the Glissonean approach for MIALR is important.

Laparoscopic resection of liver tumors in children

BACKGROUND

Laparoscopy for the resection of liver tumors in children has remained undeveloped in comparison to adults. Most of the indications for pediatric laparoscopic hepatic surgery have been limited to diagnostic laparoscopy (biopsy). Over the past ten years, however, laparoscopic liver resections for pediatric hepatic diseases have been performed successfully, and many case reports have been published.

METHODS

The authors report 6 cases of laparoscopic hepatic resection of benign tumors in children. The most important aspects of surgical technique are presented. There were 3 boys and 3 girls, with age between 4 months and 16 years. The lesions were located in the following segments: II and III (4 patients), I (1), V (1). The maximum tumor size was 7 cm.

RESULTS

One anatomical (left bisegmentectomy) and 5 nonanatomical resections were performed. Conversion to laparotomy was necessary in 1 patient owing to bleeding from the posterior branch of the right hepatic artery. There were no postoperative complications and patients were discharged on postoperative day 4, 5, 5, 5, 7 and 3 accordingly. The postoperative pathology of the specimens confirmed their benign nature: infantile hemangioendothelioma (1), nested stromal epithelial tumor (1), focal nodular hyperplasia (3), mixed benign tumor (hamartoma + vascular malformation) (1).

CONCLUSIONS

This report demonstrates the feasibility of a laparoscopic hepatic resection in children. On the other hand, laparoscopic liver resection is challenging and teamwork and specific training are necessary.

Landmarks to identify segmental borders of the liver: A review prepared for PAM-HBP expert consensus meeting 2021

BACKGROUND

In preparation for the upcoming consensus meeting in Tokyo in 2021, this systematic review aimed to analyze the current available evidence regarding surgical anatomy of the liver, focusing on useful landmarks, strategies and technical tools to perform precise anatomic liver resection (ALR).

METHODS

A systematic review was conducted on MEDLINE/PubMed for English articles and on Ichushi database for Japanese articles until September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN).

RESULTS

A total of 3169 manuscripts were obtained, 1993 in English and 1176 in Japanese literature. Subsequently, 63 English and 20 Japanese articles were selected and reviewed. The quality assessment of comparative series and case series was revealed to be usually low; only six articles were qualified as high quality. Forty-two articles focused on analyzing intersegmental/sectional planes and their relationship with specific hepatic landmark veins. In 12 articles, the authors aimed to investigate liver surface anatomic structures, while 36 articles aimed to study technological tools and contrast agents for surgical segmentation during ALR. Although Couinaud's classification has remained the cornerstone in daily diagnostic/surgical practices, it does not always portray the realistic liver segmentation and there has been no standardization on which a single strategy should be followed to perform precise ALR.

CONCLUSIONS

A global consensus should be pursued in order to establish clear guidelines and proper recommendations to perform ALR in the era of minimally invasive surgery.

Landmarks and techniques to perform minimally invasive liver surgery: A systematic review with a focus on hepatic outflow

PURPOSE

In this systematic review, we aimed to clarify the useful anatomic structures and assess available surgical techniques and strategies required to safely perform minimally invasive anatomic liver resection (MIALR), with a particular focus on the hepatic veins (HVs).

METHODS

A systematic review was conducted using MEDLINE/PubMed for English articles and Ichushi databases for Japanese articles through September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN).

RESULTS

A total of 3372 studies were obtained, and 59 were selected and reviewed. Due to the limited number of published comparative studies and case series, the degree of evidence from our review was low. Thirty-two articles examined the anatomic landmarks and crucial structures for approaching HVs. Regarding the direction of HV exposure, 32 articles focused on the techniques and advantages of exposing HVs from either the root or the periphery. Ten articles focused on the techniques to perform a segmentectomy 8 in particularly difficult cases of MIALR. In seven articles, bleeding control from HVs was also discussed.

CONCLUSIONS

This review may help experts reach a consensus regarding the best approach to the management of hepatic veins during MIALR.

Robotic Versus Open Liver Resection in Hepatocarcinoma: Surgical and Oncological Outcomes

BACKGROUND

Minimally invasive approaches are spreading in every field of surgery, including liver surgery. However, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma are limited.

MATERIALS AND METHODS

We retrospectively reviewed demographics characteristics, pathologic features, surgical, and oncological outcomes of patients who underwent robotic and conventional open liver resection for hepatocellular carcinoma.

RESULTS

No significant differences in demographics features, tumor size, tumor location, and type of liver resection were found. The morbidity rate was similar, 23% for the open group versus 17% of the robotic group (P=0.605). Perioperative data analysis showed a greater estimated blood loss in patients who underwent open resection, if compared with robotic group (P=0.003). R0 resection and disease-free resection margins showed no statistically significant differences. The 3-year disease-free survival of the robotic group was comparable with that of the open group (54% vs. 37%; P=0.592), as was the 3-year overall survival (87% vs. 78%; P=0.203).

CONCLUSIONS

The surgical and the oncological outcomes seem to be comparable between minimally invasive and open hepatectomy. Robotic liver resections are effective, and do not compromise the oncological outcome, representing a reasonable alternative to the open approach.

Improved Outcomes of Laparoscopic Liver Resection for Hepatocellular Carcinoma Located in Posterosuperior Segments of the Liver

BACKGROUND

LLR is widely adapted for HCC, while LLR in PS segments is still challenging. With recent improvement of techniques and accumulation of experiences, LLR in PS segments is feasible, but studies investigating the result after the modifications are lacking.

METHODS

In this single-center, retrospective study, 149 patients who underwent LLR for HCC located in PS segments from September 2003 to December 2016 were analyzed. The patients were divided into Group 1 (n=43) and Group 2 (n=106) who underwent LLR before and after 2012, respectively, when advanced techniques including use of intercostal trocars, Pringle maneuver, and semi-lateral position of patient were introduced. Also, these patients were compared with those who underwent open liver resection (OLR; n=124) for HCC in PS segments during the same period.

RESULTS

Mean operative time (394.7 minutes vs 331.2 minutes; P=0.013), intraoperative blood loss (1545.8 ml vs 1208.2 ml; P=0.020), and hospital stay (11.6 days vs 9.2, P<0.001) were significantly less in Group 2. Postoperative complication rate (18.6% vs 18.9%; P=0.970), open conversion rate (23% vs 17%; P=0.374), 5-year overall (79% vs 89%; P=0.607) and 5-year disease-free (52% vs 53%; P=0.657) survival rates were not significantly different between the groups. Compared to the OLR group, complication rate (40.3% vs 18.8%; P< 0.001) and hospital stay (17.6 days vs 9.7 days; P< 0.001) were significantly lower in the LLR group.

CONCLUSION

The complexity of LLR for HCC in PS segments is being gradually overcome by the introduction of advanced techniques.

Robotic Liver Surgery - Current Standards and Future Perspectives

BACKGROUND

 Robotic liver surgery is emerging as the future of minimal invasive surgery. The robotic surgical system offers a stable camera platform, elimination of physiologic tremor, augmented surgical dexterity as well as improved ergonomics because of a seated operating position. Due to the theoretical advantages of the robotic assisted system, complex liver surgery might be an especially interesting indication for a robotic approach since it demands delicate tissue dissection, precise intracorporeal suturing as well as difficult parenchymal transection with subsequent need for meticulous hemostasis and biliostasis.

MATERIAL AND METHODS

 An analysis of English and German literature on open, laparoscopic and robotic liver surgery was performed and this review provides a general overview of the existing literature along with current standards and aims to specifically point out future directions of robotic liver surgery.

RESULTS

 Robotic liver surgery is safe and feasible compared to open and laparoscopic surgery, with improved short-term postoperative outcomes and at least non-inferior oncological outcomes.

CONCLUSION

 In complex cases including major hepatectomies, extended hepatectomies with biliary reconstruction and difficult segmentectomies of the posterior-superior segments, robotic surgery appears to emerge as a reasonable alternative to open surgery rather than being an alternative to laparoscopic procedures.

Impact on operative outcomes of laparoscopic simultaneous resection of colorectal cancer and synchronous liver metastases

INTRODUCTION

The efficacy of laparoscopic simultaneous resection of primary colorectal cancer and synchronous colorectal liver metastases (SCRLM) remains unclear.

METHODS

We retrospectively evaluated data from 258 patients who had undergone simultaneous curative resection of the primary tumor and SCRLM from 2006 to 2017. We compared surgical outcomes between open, hybrid (laparoscopic colorectal resection and open hepatectomy), and pure laparoscopic approaches. Surgical outcomes were also evaluated between the open hepatectomy (OH) group (ie, open/hybrid surgery) and the laparoscopic hepatectomy (LH) group (ie, pure laparoscopic surgery) in 141 patients later in the study period (2013-2017), when the clinical indications for laparoscopic hepatectomy were restricted to simple wedge resection and/or left lateral sectionectomy in our center.

RESULTS

The pure laparoscopic approach was associated with significantly less intraoperative blood loss and a significantly shorter postoperative hospital stay than the open and hybrid approaches. Late in the study period, operative outcomes in the LH group (n = 37) were more favorable than for the OH group (n = 104) in terms of intraoperative blood loss and postoperative hospital stay. In patients with rectal cancer, however, earlier postoperative recovery in the LH group did not differ significantly from the OH group.

CONCLUSION

Laparoscopic simultaneous resection of SCRLM with the primary tumor by simple hepatectomy is safe and may enhance patients' postoperative recovery, especially in patients with colon cancer.

Left Hepatic Vein Preferential Approach Based on Anatomy Is Safe and Feasible for Laparoscopic Living Donor Left Lateral Sectionectomy

We assess the safety and feasibility of the left hepatic vein preferential approach (LHVPA) based on left hepatic vein (LHV) anatomy for living donor laparoscopic left lateral sectionectomy (LLLS). Data from 50 donors who underwent LLLS in Huashan Hospital from October 2016 to November 2019 were analyzed retrospectively. On the basis of the classification of the LHV anatomy, the vein was defined as the direct import type, upper branch type, or indirect import type. A subgroup analysis was performed to compare the outcomes between the LHVPA and non-LHVPA groups. All 50 patients underwent pure LLLS. The mean operative duration was 157.5 ± 29.7 minutes. The intraoperative blood loss was 160.4 ± 97.5 mL. No complications more severe than grade 3 occurred. LHVPA was applied in 13 patients, whereas non-LHVPA was applied in 10 patients with the direct import type and upper branch type anatomy. The operative duration was shorter in the LHVPA group than the non-LHVPA group (142.7 ± 22.0 versus 173.0 ± 22.8 minutes; P = 0.01). Intraoperative blood loss was reduced in the LHVPA group compared with the non-LHVPA group (116.2 ± 45.6 versus 170.0 ± 63.3 mL; P = 0.02). The length of the LHV reserved extrahepatically in the LHVPA group was longer than in the non-LHVPA group (4.3 ± 0.2 versus 3.3 ± 0.3 mm; P = 0.01). Fewer reconstructions of the LHV in the direct import type anatomy were required for the LHVPA group than for the non-LHVPA group (0/8 versus 4/6). LHVPA based on the LHV anatomy is recommended in LLLS because it can further increase the safety and the efficiency of surgery for suitable donors.

Pure Laparoscopic Donor Hepatectomy: A Multicenter Experience

According to recent international consensus conferences, pure laparoscopic donor hepatectomy (PLDH), particularly right and left hepatectomies, is not yet considered a standard practice because studies remain limited. Thus, we present the outcomes of more than 500 PLDH patients, mostly receiving a right hepatectomy. To our knowledge, this is the largest study to date on PLDH. Data from all living liver donors who underwent PLDH at 5 centers in Korea until June 2018 were retrospectively analyzed. The outcomes of both donors and recipients were included. Pearson correlation analysis was used to explore the relationship between the duration of surgery and cumulative experience at each center, which reflects the learning curve. Overall, 545 PLDH cases were analyzed, including 481 right hepatectomies, 25 left hepatectomies, and 39 left lateral sectionectomies (LLS). The open conversion was necessary for 10 (1.8%) donors, and none of the donors died or experienced irreversible disability. Notably, there were 25 (4.6%) patients with major complications (higher than Clavien-Dindo grade 3). All centers except one showed a significant decrease in surgery duration as the number of cases accumulated. Regarding recipient outcomes, there were 110 cases (20.2%) of early major complications and 177 cases (32.5%) of late major complications. This study shows the early and late postoperative outcomes of 545 donors and corresponding recipients, including 481 right hepatectomies and 25 left hepatectomies, from 5 experienced centers. Although the results are comparable to those of previously reported open donor hepatectomy series, further studies are needed to consider PLDH a new standard practice.

Outcome of minimally invasive liver resection for extrapancreatic biliary malignancies: A single-institutional experience

Background:

Minimally invasive liver resection (MILR) has been increasingly adopted over the past decade, and its application has been expanded to the management of extrapancreatic biliary malignancies (EPBMs). We aimed to evaluate the peri- and post-operative outcome of patients undergoing MILR for suspected EPMB.

Methods:

Forty-four consecutive patients who underwent MILR with a curative intent for EPBM at Singapore General Hospital between 2011 and 2018 were identified from a prospectively maintained surgical database. Clinical and operative data were analysed and compared to provide information and make comparisons on peri- and post-operative outcomes.

Results:

A total of 26, 5 and 13 patients underwent MILR for intrahepatic cholangiocarcinoma (ICC), perihilar cholangiocarcinoma (PHC) and gallbladder carcinoma (GBCA), respectively. Six major hepatectomies were performed, of which one was laparoscopic assisted and another was robot assisted. Ten patients underwent posterosuperior segmentectomies. There was one open conversion. The mean operative time was 266.5 min, and the mean blood loss was 379 ml. The mean length of hospital stay was 4.7 days with no incidences of 30- and 90-day mortality. The rate of recurrence-free survival (RFS) was 75% (at least 12-month follow-up). There was a significantly higher rate of robot-assisted procedures in patients undergoing MILR for GBCA/PHC as compared to ICC (P = 0.034). Patients undergoing posterosuperior segmentectomies required longer operative time (P = 0.018) with an increased need for (P = 0.001) and duration of (P = 0.025) Pringles manoeuvre. There were no differences in operative time, blood loss, morbidity, mortality or RFS between the above groups.

Conclusion:

Minimally invasive surgery can be adopted safely with a low open conversion rate for EPBMs.

Surgical Treatment of Intrahepatic Cholangiocarcinoma: Current and Emerging Principles

Intrahepatic cholangiocarcinoma (ICC) is a rare, aggressive cancer of the biliary tract. It often presents with locally advanced or metastatic disease, but for patients with early-stage disease, surgical resection with negative margins and portahepatis lymphadenectomy is the standard of care. Recent advancements in ICC include refinement of staging, improvement in liver-directed therapies, clarification of the role of adjuvant therapy based on new randomized controlled trials, and advances in minimally invasive liver surgery. In addition, improvements in neoadjuvant strategies and surgical techniques have enabled expanded surgical indications and reduced surgical morbidity and mortality. However, recurrence rates remain high and more effective systemic therapies are still necessary to improve recurrence-free and overall survival. In this review, we focus on current and emerging surgical principals for the management of ICC including preoperative evaluation, current indications for surgery, strategies for future liver remnant augmentation, technical principles, and the role of neoadjuvant and adjuvant therapies.

Propensity score matching analysis for outcomes of laparoscopic versus open caudate lobectomy

BACKGROUND

To date, laparoscopic caudate lobectomy (LCB) remains a challenge, and evidence about its value is rare. Therefore, this study was performed to assess the benefits of LCB for patients with tumours located in the caudate lobe compared with open caudate lobectomy (OCB).

METHODS

From October 2015 to June 2019, 102 patients meeting the inclusion and exclusion criteria were eligible for this study. The patients were divided into LCB and OCB groups. Short-term outcomes between the groups were compared with propensity score matching (PSM).

RESULTS

LCB was performed in 31 of the 102 included patients. After PSM, 30 patients with well-balanced baseline levels were enrolled in each group. Intraoperative blood loss in the LCB group was less than that in the OCB group (median, 100 versus 200 mL, P = 0.017), even though it did not reach a statistically significant difference after PSM (median, 100 versus 187.5 mL, P = 0.085). Moreover, although post-operative overall complications were similar in the two groups, a tendency of lower rates of respiratory infection in the LCB group than the OCB group was observed (0% versus 12.7%, P = 0.054 before PSM; 0% versus 16.7%, P = 0.063 after PSM). There was no early mortality in either group. LCB had a shorter post-operative hospital stay than OCB (median, 5 versus 6 days, P < 0.001). However, the hospitalization cost was higher in the LCB group than in the OCB group (P < 0.001).

CONCLUSION

LCB is safe and feasible in selected patients when performed by experienced surgeons.

Laparoscopic Major Hepatectomy: Do Not Underestimate the Impact of Specimen Extraction Site

BACKGROUND

In laparoscopic major hepatectomy, analysis of outcomes according to specimen extraction site remains poorly described. The aim was to compare postoperative outcomes according to specimen extraction site.

METHODS

From 2000 to 2017, all laparoscopic major hepatectomies were reviewed and postoperative outcomes were analyzed according to specimen extraction site: subcostal (Group 1), midline (Group 2), or suprapubic (Group 3) incision.

RESULTS

Among 163 patients, 15 (9.2%) belonged to Group 1, 49 (30.1%) in Group 2, and 99 (60.7%) in Group 3. The proportion of right-sided, left-sided, or central hepatectomies, mortality, and overall and severe complications were comparable between groups. Group 1 had larger tumors (61 vs. 38 vs. 47 mm; P = 0.014), higher operative time (338 vs. 282 vs. 260 min; P < 0.008), higher adjacent organ resection rate (46.6 vs. 16.3 vs. 7.1%; P < 0.001), and tended to increase pulmonary complications (40.0 vs. 12.2 vs. 18.2%; P = 0.064). In Group 2, a previous midline incision scar was more frequently used for specimen extraction site (65.3 vs. 26.6 and 30.3%, Group 1 and 3; P < 0.001). Postoperative incisional hernia was observed in 16.4% (n = 23) and was more frequent in Group 2 (26.6 vs. 6.6% and 10.1%, Group 1 and Group 3; P = 0.030). Finally, Group 2 (HR 2.63, 95% CI 1.41-3.53; P = 0.032) was the only independent predictive factor of postoperative incisional hernia.

CONCLUSIONS

While using a previous incision makes sense, the increased risk of postoperative incisional hernia after midline incision promotes the suprapubic incision.

Meta-analysis of laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) is a rare and aggressive hepatic malignancy. An up-to-date systematic review and meta-analysis was conducted aiming to compare outcomes between laparoscopic (LLR) and open liver resection (OLR) for patients with iCCA. A systematic literature search of Medline, Scopus, Google Scholar, and Cochrane databases was performed. A total of 8 studies comprising 2872 patients, who underwent LLR or OLR for iCCA, were included in our meta-analysis. LLR patients had smaller tumors [mean difference (MD): - 1.17 cm, 95% confidence intervals (CI) - 1.77 to - 0.57, p = 0.0001], underwent major resections less frequently [risk ratio (RR): 0.75, 95% CI 0.67-0.83, p < 0.00001] and R0 resections more frequently (RR: 1.05, 95% CI 1.01-1.09, p = 0.01), while lymphadenectomy was less common in the laparoscopic group (RR: 0.73, 95% CI 0.58-0.92, p = 0.007). The LLR group presented reduced blood loss (MD: - 270.16 ml, 95% CI - 381.53 to - 32.79, p = 0.002), need for transfusion (RR: 0.39, 95% CI 0.21-0.73, p = 0.003), overall morbidity (RR: 0.58, 95% CI 0.4-0.83, p = 0.003) and hospital stay (MD: - 3.48 days, 95% CI: - 6.94 to - 0.02, p = 0.05) compared to the OLR group. No differences were shown in operative time (MD: 1.6 min, 95% CI - 34.17-37.37, p = 0.93), major morbidity (RR: 0.65, 95% CI 0.38-1.11, p = 0.12), mortality (RR: 1.42, 95% CI 0.13-15.07, p = 0.77), overall (HR: 0.9, 95% CI 0.59-1.38, p = 0.63) and relapse-free survival (HR: 0.77, 95% CI 0.5-1.16, p = 0.21) between the two groups. LLR seems to benefit patients with iCCA in terms of short-term outcomes, whilst long-term outcomes are comparable among the two approaches.

The impact of robotics in liver surgery: A worldwide systematic review and short-term outcomes meta-analysis on 2,728 cases

BACKGROUND

The dissemination of robotic liver surgery is slow-paced and must face the obstacle of demonstrating advantages over open and laparoscopic (LLS) approaches. Our objective was to show the current position of robotic liver surgery (RLS) worldwide and to identify if improved short-term outcomes are observed, including secondary meta-analyses for type of resection, etiology, and cost analysis.

METHODS

A PRISMA-based systematic review was performed to identify manuscripts comparing RLS vs open or LLS approaches. Quality analysis was performed using the Newcatle-Ottawa score. Statistical analysis was performed after heterogeneity test and fixed- or random-effect models were chosen accordingly.

RESULTS

After removing duplications, 2728 RLS cases were identified from the final set of 150 manuscripts. More than 75% of the cases have been performed on malignancies. Meta-analysis from the 38 comparative reports showed that RLS may offer improved short-term outcomes compared to open procedures in most of the variables screened. Compared to LLS, some advantages may be observed in favour of RLS for major resections in terms of operative time, hospital stay and rate of complications. Cost analyses showed an increased cost per procedure of around US$5000.

CONCLUSIONS

The advantages of RLS still need to be demonstrated although early results are promising. Advantages vs open approach are demonstrated. Compared to laparoscopic surgery, minor perioperative advantages may be observed for major resections although cost analyses are still unfavorable to the robotic approach.

Robotic versus open hemihepatectomy: a propensity score-matched study

BACKGROUND

Minimally invasive approach has been increasingly applied in liver resection. However, laparoscopic major hepatectomy is technically demanding and is practiced only in expert centers around the world. Conversely, use of robot may help to overcome the difficulty and facilitate major hepatectomy.

METHODS

Between September 2010 and March 2019, 151 patients received robotic hepatectomy for various indications in our center. 36 patients received robotic hemihepatectomy: 26 left hepatectomy and 10 right hepatectomy. During the same period, 737 patients received open hepatectomy and out of these, 173 patients received open hemihepatectomy. A propensity score-matched analysis was performed in a 1:1 ratio.

RESULTS

After matching, there were 36 patients each in the robotic and open group. The two groups were comparable in demographic data, type of hemihepatectomy, underlying pathology, size of tumor, and background cirrhosis. Conversion was needed in 3 patients (8.3%) in the robotic group. There was no operative mortality. The operative blood loss and resection margin were similar. Though not significantly different, there was a higher rate of complications in the robotic group (36.1% vs. 22.2%) and this difference was mostly driven by higher intra-abdominal collection (16.7% vs. 5.6%) and bile leak (5.6% vs. 2.8%). Operative time was significantly longer (400.8 ± 136.1 min vs 255.4 ± 74.4 min, P < 0.001) but the postoperative hospital stay was significantly shorter (median 5 days vs 6.5 days, P = 0.040) in the robotic group. When right and left hepatectomy were analyzed separately, the advantage of shorter hospital stay remained in left but not right hepatectomy. For patients with hepatocellular carcinoma, there was no difference between the two groups in 5-year overall and disease-free survival.

CONCLUSION

Compared with the open approach, robotic hemihepatectomy has longer operation time but shorter hospital stay. Thus, use of robot is feasible and effective in hemihepatectomy with the benefit of shorter hospital stay.